To Enroll in Liberty Advantage, Please Provide the Following Information:

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Please contact Liberty Advantage if you need information in another language or format (Braille). To Enroll in Liberty Advantage, Please Provide the Following Information: LAST name: FIRST Name: Middle Initial: Mr. Mrs. Ms. Birth Date: ( / / ) (M M / D D / Y Y Y Y) Sex: M F Home Phone Number: ( ) Alternate Phone Number: ( ) Permanent Residence Street Address (P.O. Box is not allowed): City: [County:] State: ZIP Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: Phone Number: Relationship to You: E-mail Address: Please Provide Your Medicare Insurance Information Please take out your red, white and blue Medicare card to complete this section. Fill out this information as it appears on your Medicare card. - OR - Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. Name (as it appears on your Medicare card: Medicare Number: Is Entitled To: Effective Date: HOSPITAL (Part A) MEDICAL (Part B) You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Paying Your Plan Premium If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Liberty Advantage the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800- 772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. If you don t select a payment option, you will get a bill each month. Please select a premium payment option: Get a bill each month Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from: Social Security RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums).

Please read and answer these important questions: 1. Do you have End-Stage Renal Disease (ESRD)? Yes No If you have had a successful kidney transplant and/or you don t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we may need to contact you to obtain additional information. 2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to Liberty Advantage? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage: ID # for this coverage: Group # for this coverage: 3. Are you a resident in a long-term care facility, such as a nursing home? Yes No If yes, please provide the following information: Name of Institution: Address & Phone Number of Institution (number and street): 4. Are you enrolled in your State Medicaid program? Yes No If yes, please provide your Medicaid number: 5. Do you or your spouse work? Yes No 6. Liberty Advantage is an Institutional Special Needs Plan. To be eligible to enroll in Liberty Advantage you must, for 90 days or longer, have been a resident or expect to be a resident of a long term care (LTC) skilled nursing facility (SNF), or LTC nursing facility (NF) in the Liberty Advantage network. Have you been a resident in a long-term care facility, such as a nursing home, in the Liberty Advantage network for more than 90 days? Yes No Please choose the name of a Primary Care Physician (PCP), clinic or health center: Physician Name: Is this your current physician? Yes No Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: Spanish Auto Tape or Large Print Please contact Liberty Advantage at 1-844-854-6884 if you need information in another format or language than what is listed above. Our office hours are 8 a.m. to 8 p.m., Monday through Friday (except on holidays). TTY users should call 711.

Please Read This Important Information If you currently have health coverage from an employer or union, joining Liberty Advantage could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Liberty Advantage. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Please Read and Sign Below By completing this enrollment application, I agree to the following: Liberty Advantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 December 7 of every year), or under certain special circumstances. Liberty Advantage serves a specific service area. If I move out of the area that Liberty Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Liberty Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Liberty Advantage when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date Liberty Advantage coverage begins, I must get all of my health care from Liberty Advantage, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Liberty Advantage and other services contained in my Liberty Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR LIBERTY ADVANTAGE WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Liberty Advantage, he/she may be paid based on my enrollment in Liberty Advantage.

Release of Information: By joining this Medicare health plan, I acknowledge that Liberty Advantage will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Liberty Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature: Today s Date: If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: ( ) - Relationship to Enrollee Liberty Advantage Liberty Advantage is a HMO with a Medicare contract. Enrollment in Liberty Advantage depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, co-payments, and co-insurance may change on January 1 of each year. The Institutional Special Needs Plan is available to anyone with Medicare who, for 90 days or longer, has been a resident or expects to be a resident of a longterm care (LTC) skilled nursing facility (SNF), or LTC nursing facility (NF) in the Liberty Advantage network. Please contact the plan for further details at 1-844-854-6884 (TTY: 711). Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. Liberty Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Liberty Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Liberty Advantage 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別 而歧視任何人 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-854-6884 TTY: 711. 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1-844-854-6884 TTY:711 Office Use Only: Name of staff member/agent/broker (if assisted in enrollment): Plan ID #: H6351 Effective Date of Coverage: ICEP/IEP: AEP: SEP (type): Not Eligible:

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